Choice of electronic medical record software
The idea of change is not welcome to most doctors. Changing out of old clothes and workflow can be a very scary process for doctors. Training on any new system can be an intimidating process.
As a result, many physicians find themselves procrastinating and searching for the perfect electronic medical record solution that does everything with zero effort to implement. It’s almost like a quest for the Holy Grail. However, in the meantime, they remain in a rut of inefficiency by continuing to handwrite or dictate their notes.
Unfortunately, handwritten notes and recipes are not only extremely inefficient, they are notoriously illegible. According to the Institute for Safe Medical Practices, illegible prescriptions cause more than 3 million preventable adverse drug effects each year in the US.
Additionally, as documentation requirements for medical reimbursement have become increasingly stringent, illegible notes can lead to a significant reduction in income. They can also trigger time-consuming audits that ultimately result in costly fines and payment refunds to payers. This just adds another layer of potential problems for clinicians sticking with traditional methodologies.
Electronic medical records have emerged as a way to address these concerns. In fact, federal officials have recently announced a program scheduled for early 2008 that will encourage physicians to incorporate electronic medical records into their practices. The program provides cash incentives to Medicare physicians for switching to electronic medical record systems and providing the government with updates on quality improvement markers for their patients.
Despite fears among physicians resisting the switch to electronic medical records, it is possible to find EMR software with a low learning curve that will facilitate a smooth transition. Here are some questions to ask yourself when you begin your research.
Is EMR software an intuitive system?
You don’t want to spend weeks or months training on a new system. All EMR software will have a learning curve, but some are more intuitive than others. The best EMR software will be one that you adopt quickly with minimal training and allows you to create more detailed notes with less effort. The ideal system should be able to be integrated into your clinic’s daily workflow in a few weeks, rather than several months.
The right EMR solutions should save time. The old adage “time is money” applies in this situation. You don’t want to go through 100 steps just to create a simple visit note. Instead, you want an EMR software program that streamlines the charting process as much as possible. Some EMR programs require so many steps to create a note that it’s like filling a salt shaker bean by bean.
If you choose the wrong EMR software, the inefficiencies of learning and using the new system can outweigh the inefficiencies of your current non-EMR system. Look for software that offers a free trial, so you can try it out and see how easy it is to learn and use before spending a lot of money on it.
Do you have customizable templates that eliminate redundancy?
With customization, you can document your patient notes and records using the words and format of your choice, instead of being forced to use the words and format provided by the software. Many EMR programs offer global templates for all users. This “one size fits all” mentality means that all users use the same templates (ie, the same words) to describe different patients.
The result could be called a graph by approximation: trying to fit a square peg into a round hole. Some doctors have described these types of tickets as “vending machine tickets”. EMR systems with customizable templates will allow you to create notes using your own words and style, thus more closely reflecting your thoughts.
Having customizable templates means you’ll be able to save and reuse certain frequently used phrases, forms, procedure descriptions, prescriptions, etc., so you don’t have to manually re-enter them each time.
Many EMR software programs do not allow for much customization by the end user. In these cases, if customization is available, it must be done by the software company and is prohibitively expensive and time consuming to implement.
This is another reason to test the system before committing to a specific program. Well-designed EMR software should allow you to customize recipes, templates, chart formatting, follow-up letters, and aftercare instructions. Printing options for these items should also be customizable, but simple and easy to set up with minimal support.
Will your EMR software allow multimedia attachments?
Look for EMR software that allows you to attach multimedia such as photos, X-rays, scanned documents, and ECGs to your patient records. A picture is worth a thousand words and can describe injuries and other clinical findings much more accurately than words.
Photographs can also more accurately and efficiently document changes over time during subsequent visits. Having ECG scans attached to visits makes it faster and more convenient to review and compare with previous ECGs, because with just a few mouse clicks, you can have all the information you need for your patient.
Not all EMR software is created equal. Accuracy, efficiency, intuitiveness, and cost are key factors to consider when choosing EMR software. If you make the right choice, you’ll soon find yourself using electronic medical records and wondering why it took you so long to make the switch. If you continue to wait and search for the Holy Grail of EMR software, you will only prolong the inefficiencies and inadequacies, as well as the potential risks, of your current methods.